One of my primary areas of research is in conflicts of interest (COI). I generally focus on the financial relationships between physicians/researchers and the pharmaceutical industry. See Here Here and Here.
However, COI researchers and policy makers need to expand our scope to include other health care professionals who have relationships with other key health care industries, other than pharma and device companies. In this blog, I focus upon the relationships between discharge planners and long-term care providers (including home care, skilled nursing facilities and others). Long-term care is a growing part of health care expenditures, and represents an area where patients’ preferences and best-interests should be the primary obligations of discharge planning professionals — who are not biased due to industry marketing.
As I reflect back upon my almost two decades in health care, as a clinician, researcher and bioethicist, I am amazed at how pervasive marketing activities are in hospitals… other than seeing drug reps visiting doctors (in fact, this was banned in the hospital I worked). For example, during my first clinical internship, at a rural hospital near Atlanta, home care agency marketing reps were often bringing food and providing educational/marketing materials to the Case Management/Social Work office. We all hung out together. Same thing happened in NYC; although I was not directly involved in discharge planning, home care and post-acute care providers bestowed small gifts, food and other marketing materials – obviously, with the hope of building goodwill, and hoping that as a clinical social worker, I would indirectly influence referrals to their businesses. In addition to gifts and marketing, representatives from these health care companies were often ever-present in the inpatient units to help the Case Managers and other clinicians with the necessary paperwork, insurance reviews, and overall referral facilitation. From what I understand, this type of post-acute care industry “detailing” still occurs in American Hospitals with frequency.
During my many years in healthcare as a clinician, researcher and hospital ethics consultant, I am dismayed by how little relative attention is given to ensuring that surrogate decision-makers (or “proxies”) have the “capacity” to make sound medical decisions for adult patients without decision-making capacity. Some attention has been given to this in the literature, but not a lot. And, practically, it is routine in most clinical situations to defer to a proxy without much assessment of his/her capabilities.
For example, it has been demonstrated through many empirical studies that family members experience high distress when loved ones are admitted to ICUs, quite understandably — many families experience such high distress that decision-making abilities can be compromised. Others, even if distress is well-managed, are simply not aware of the patients’ previously stated wishes, to enable them to make decisions based upon substituted judgment. And, still others may not know enough of the medical situation to make good decisions based upon the patient’s best interests. Then, sadly, we also have a portion of proxies who may not want to keep the best interests of the patient at heart — in fact, I have done research among people with cancer who are also suffering from domestic violence from their primary caregiver (and presumed proxy). In these situations, the proxy may actually want to cause harm to the patient. Or, another example is when the harm may not be intended, but the proxy makes decisions based upon their own needs. An example is a proxy who chooses to keep a person in a terminal condition on life-support for their own financial gain (for pension checks to keep coming, for example).
We need to pay more attention to the capabilities of health care proxies. For example, in addition to encouraging clinicians to assess patients’ decision-making capabilities, clinicians should also be assessing the proxies’ decision-making abilities – early in the process. However, to my knowledge, there are no clear methods, guidelines, policies or laws “removing” established proxies from their posts as decision-makers (aside from taking the person to court, which is often impractical), when their judgment seems compromised. Clinicians are often left without guidance. Perhaps folks in clinical bioethics can help establish some clear standards for proxy decision-making, which might serve as a guide for clinicians, but also for future policy development. Just some initial thoughts…
The Dartmouth Atlas of Health Care recently published a report entitled, “What Kind of Physician Will You Be?: Variation in Health Care and Its Importance for Residency Training.” (2012; http://www.dartmouthatlas.org/pages/residency). Briefly, this report analyzes Medicare data to create indexes and variables used to describe varying levels of treatment intensity, particularly at the end of life, for 23 top U.S. medical centers. This report is targeted to medical students who are choosing their residency programs, hoping that prospective residents look at a wider-array of factors, including: how well these hospitals utilize effective, proven health care interventions; to what extent the care they provide is dependent on supply-induced demand; and how well the hospitals allow for patient preferences in treatment plans.
This report grabbed my attention given that I conduct research in end-of-life (EOL) care, and I am sympathetic to efforts to improve the quality of care provided to people with advanced and terminal diseases. I am also quite interested in how our medical system can change the culture of medical care to provide higher-quality EOL, and to reduce the use of often ineffective and invasive medical interventions, particularly through hospitalization and ICU admissions. The education of residents seems like a good place to start in changing the current intensity and specialty-driven culture.
However, the gaps in this report compromise its arguments and potentially reduce its effectiveness. I will only highlight two here.